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One bed is available on the eating disorders unit. Which patient should be admitted? The patient whose assessment findings show the weight dropped from:
- A. 150 to 102 pounds over a 4-month period.
- B. 120 to 90 pounds over a 3-month period.
- C. 130 to 100 pounds over a 2-month period.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because the patient has experienced a significant weight drop from 150 to 102 pounds over a 4-month period. This represents a loss of 48 pounds over a relatively longer period, indicating a more severe and prolonged issue with weight loss. The other choices show weight drops of 30 pounds over 3 months (B) and 30 pounds over 2 months (C), which are also concerning but not as severe or long-lasting as the situation described in choice A. Choice D is incorrect as at least one patient should be admitted based on the information provided.
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An elderly patient must be physically restrained. Who is responsible for the patient's safety?
- A. The nurse assigned to care for the patient
- B. Unlicensed assistive personnel who apply the restraint
- C. Family member who agrees to application of the restraint
- D. Health care provider who prescribed application of restraint
Correct Answer: A
Rationale: The correct answer is A: The nurse assigned to care for the patient. The nurse is responsible for the patient's safety because they are the primary caregiver and have the training and knowledge to ensure proper application of restraints, monitor the patient's condition, and respond to any potential complications. Unlicensed assistive personnel (choice B) may apply restraints under the nurse's supervision but do not have the same level of training or accountability. Family members (choice C) and healthcare providers (choice D) may be involved in the decision-making process, but ultimate responsibility for patient safety lies with the nurse who directly cares for the patient.
Which would be the best initial approach for a nurse to select when managing the care of an individual with two children who works full-time and has been abused by a partner?
- A. Teach the individual how to avoid provoking the abuser.
- B. Assist the individual in filing a police report describing the abuse.
- C. Help the individual to identify needs in order to best obtain support.
- D. Facilitate the individual's move into a safe house located near the current workplace.
Correct Answer: C
Rationale: The correct answer is C: Help the individual to identify needs in order to best obtain support. This is the best initial approach because it focuses on understanding the individual's specific needs and circumstances before taking any further action. By identifying needs, the nurse can create a tailored plan to provide appropriate support and resources.
Option A is incorrect because teaching the individual to avoid provoking the abuser places the responsibility on the victim rather than addressing the root cause of the abuse. Option B, filing a police report, may not be the best initial step as it may not take into consideration the individual's safety concerns or emotional well-being. Option D, moving the individual to a safe house, may not be feasible or desired by the individual without first understanding their needs and preferences.
The nurse has recently set limits for a patient with borderline personality disorder. The patient tells the nurse, 'You used to care about me. I thought you were wonderful. Now I can see I was mistaken. You're hateful.' Which phenomenon is represented by this response?
- A. Splitting
- B. Denial
- C. Reaction formation
- D. Projection
Correct Answer: A
Rationale: The correct answer is A: Splitting. Splitting is a defense mechanism commonly seen in individuals with borderline personality disorder where they perceive others as either all good or all bad. In this scenario, the patient's sudden shift from viewing the nurse as wonderful to hateful demonstrates splitting. The patient is unable to integrate both positive and negative aspects of the nurse's behavior, leading to extreme and polarized perceptions.
Choice B: Denial involves refusing to accept reality to protect oneself from uncomfortable truths, which is not demonstrated in this response.
Choice C: Reaction formation is a defense mechanism where an individual behaves in a way that is opposite to their true feelings, which is not evident in the patient's response.
Choice D: Projection involves attributing one's own unacceptable thoughts or feelings onto someone else, which is not the case in this scenario.
A patient with schizophrenia tells the nurse, 'Everyone must listen to me. I am the redeemer. I will bring peace to the world.' From this the nurse can determine that an appropriate nursing diagnosis is:
- A. Disturbed sensory perception: auditory.
- B. Risk for other-directed violence.
- C. Chronic low self-esteem.
- D. Nonadherence: medication.
Correct Answer: C
Rationale: Step 1: The patient's statement indicates grandiosity and delusions of grandeur, common in schizophrenia.
Step 2: Chronic low self-esteem is a common nursing diagnosis for those with grandiose delusions.
Step 3: The patient's belief of being the redeemer suggests underlying feelings of inadequacy.
Step 4: Addressing self-esteem can help the patient cope with such delusions.
Summary: A is incorrect as there is no mention of auditory hallucinations. B is incorrect as there is no immediate threat of violence. D is incorrect as nonadherence to medication is not evident in the scenario.
An 83-year-old man becomes lost while driving. He pulls into a driveway to turn around and cannot figure out how to put his car in reverse, so he drives into the yard, makes a circle, and drives back out of the driveway. He is stopped by police, who take him to the emergency department. The physician diagnoses him with Alzheimer's disease and refers him to the neurology clinic for follow-up. Given this diagnosis, which behaviors should the clinic nurse anticipate?
- A. Does not know today's date.
- B. Unable to shower without help.
- C. Denial of mental impairment.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Does not know today's date. This behavior is commonly associated with Alzheimer's disease due to memory impairment. The inability to recall the current date is a key symptom of cognitive decline. In this case, the man's difficulty with reversing his car and getting lost are indicative of cognitive impairment.
Choice B, Unable to shower without help, is a functional impairment and not specific to Alzheimer's disease. Choice C, Denial of mental impairment, may occur in some individuals with Alzheimer's but is not a consistent behavior. Choice D, None of the above, is incorrect as memory deficits, such as not knowing the date, are commonly seen in Alzheimer's disease.